Dr John Crippen: A fair contribution at the point of entry

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Dr John "Crippen", of NHS Blog Doctor, is
a full time family doctor working somewhere north of London. He is grateful to Wat Tyler, of Burning Our Money, for detailed advice on health care finance.

Free at the point
of entry? Free at the point of need?

The newspapers
highlighted the tragic case of a young women, aged only 26, who died recently
of bowel cancer. Assisted by family and friends she spent the last few weeks of
her life begging and borrowing money to buy a private prescription for Avastin, a drug that her
PCT (Primary Care Trust) would not fund.

Examples like this
are legion. They make excellent journalistic copy. They are the tip of an
iceberg that no politician to date has been able to acknowledge.

The facts are
simple. No country can afford to provide
its citizens with all that modern medical technology has to offer.

Britain has been the health care miser of Europe,
spending less than 7% of GDP on health. Tony Blair pledged to match the European average of 8%. We duly increased our expenditure from 7% to
8% of GDP but by the time we got there, the European average was over 9%. It is
a moving target.

And who is to say
that Europe has got it right? The USA spends a
massive 15% of their GDP on health.

The total world
health care spend is currently $3 trillion. For those who like their noughts,
that is $3,000,000,000,000. It gets worse. Health care is the world’s largest
industry, bigger even than defence, and it is growing at twice the rate of the
world GDP. By the year 2100 it will account for…everything. The total world GDP
will be spent on health care.

The choice is
ours.

We can take control.
We can abandon short-termism. We can stop tinkering around the edges. We can
look at the radical changes that are needed to control this modern Leviathan.

If we do not take control, decent health care
will eventually only be available for the rich. The seeds are already sown. It
is happening in the USA.
It is beginning to happen here.

Society (that is a
pompous word for "you and me") needs to understand that our infinite health care capability
has to be rationed. It is already being rationed in the UK by stealth;
by the postcode lottery, by waiting lists and, most of all, by dumbing down the
service provided for those without private health insurance.

Private patients
and the “great and the good” see doctors. NHS patients see nurse-specialists,
EMTs and a whole range of (latest buzz word approaching) “Health Care
Professionals”. The expression, “Health
Care Professional” has an air of New Labour plausibility. It means “we cannot
afford to provide a doctor”.

There is
breathtaking financial irresponsibility within the NHS. To take but one
example. £20 billion and rising spent on an IT system. As Richard Bacon MP said:

"At a time
when hard-pressed NHS trusts are having to make painful choices to reduce
deficits, they are being forced to pay money they don’t have and release staff
they can’t spare, for something they don’t want and which doesn’t work …"

The NHS is a
nationalised industry. No amount of government controls, checks, targets and
bean counting are a substitute for the financial accountability of a free
market economy.

Twelve years ago
there was a glimmer of hope. GPs were allowed to become “fund-holders”. In simple terms, a system in which “the money
followed the patient”. The hospitals competed to attract work from
well-organised fundholding practices. The care our patients received improved.

When New Labour
came to power in 1997, for purely doctrinal reasons, they abolished
fundholding. Not only did they abolish fundholding, which was relatively new,
but they also abolished the freedom of choice of referral which family doctors
had had since the inception of the health service. We were compelled to send
all our patients to the local hospital. The hospitals no longer had to compete
for our custom. The standard of service declined.

The Labour
government has recognised the merits of fundholding and is re-introducing it.
Under a different name of course. This time it is to be called Practice Based
Commissioning (PBC). It is difficult not to smile. Sadly, it is unlikely to
work. The government hatred of professional autonomy is so great that they are
tying PBC up in a network of committee based bureaucratic controls which will
stifle initiative.

There has to be a
re-introduction of the principle of a free market economy within the NHS. We had a taste of it in the nineties. Heady
days! Let the doctors get on with their jobs. Let the money follow the patient.
Hospitals and general practices that deliver will thrive. The ones that do not
deliver will fail. Let them. The fact that we are working in health care is no
reason to buttress the incompetent.

Finally, the most
difficult area. Financial
irresponsibility from the outside of the system, from the health care consumer.
The patients. That which is free, or perceived to be free, is not valued.

A family doctor
colleague from New Zealand
wrote to me recently about his experience of working in the UK:

"I worked in the UK for a few
weeks. I could not believe that you did not have to pay to see a GP, but that
it took two days to get an appointment. I was staggered by the trivia, by the
nonsense. The number of people, for example, who attended with bad colds. Here
in New Zealand it costs the equivalent of £30 to see a GP. It may a barrier to someone
with a bad cold but, when you are really ill, you can get an immediate appointment.
I prefer our system."

The mantra of
health care in the UK
is “free at the point of entry.” It is a
beguiling catch phrase, a wonderful slogan. But it is no longer true and
probably never was wholly true.

There is only free
entry to the NHS when the door is open. For many it is closed. Dr Crippen has
patients still waiting after a year for surgery for the same cardiac problems
that afflicted the Prime Minister. PCTs refuse to finance expensive cancer
drugs. Patients with ischaemic heart disease on the “non-urgent” (sic) waiting
list die before they get surgery.

The list is long.

A nettle has to be
grasped. We have to think the unthinkable. Speak the unspeakable.

When Tony Blair
became leader of the Labour Party, one of his first political moves was to
ditch Clause IV. In practice, Clause IV meant nothing. But doctrinally, its
abolition was a courageous political move. It took New Labour into new
political territory.

We need to accept
that the finance is not available to allow free, instant access to healthcare
for any condition, however trivial. “Free at the point of entry” is the Clause
IV of the NHS.

It has to go.

Unrealistic
expectations and excessive, wasteful health care demands can only be controlled
by a front end charge and by a direct contribution from the patient towards the
cost of ongoing medical care.

It will not be
easy. It will need to be properly safety netted. But if a politician can find a
way of making this acceptable to the public, there is a real possibility of
genuine equality of health care.

“A fair contribution at the point of entry”
should become the new, and realistic, health care slogan.